Understanding Palliative & End of Life Care: The Menagerie (Parts 1 & 2)

The only two-part episode during Star Trek’s Original Series run, “The Menagerie” aired on November 17th (part one) and November 24th (part two) 1966. This episode allowed the Star Trek producers to ease the pressure and cost of putting out a new episode every week by reusing footage from the unaired pilot (“The Cage”) and splicing it in with some newly shot scenes. It also allowed Roddenberry to work around the network and make his original vision of the series still part of the overall canon.

Synopsis (from IMDB):

Spock kidnaps the crippled Capt. Pike, hijacks the Enterprise and then surrenders for court martial.

It might also help to know the synopsis for the original pilot, “The Cage,” from which the scenes were spliced into for the two-part episode (also from IMDB):

Capt. Pike is held prisoner and tested by aliens who have the power to project incredibly lifelike illusions.

The newer J.J. Abrams films have really increased the public’s exposure to the character of Captain Pike; however, back in the 1960s, this two-part episode served for viewers as both an introduction to Pike, and his relationship with Spock, as well his send-off from the series. In “The Menagerie,” Spock’s loyalty to his former captain trumps his own self-preservation as he risks everything to bring the now crippled Captain Pike back to the planet and the aliens who held him hostage many years ago. The reasoning behind this is slowly unraveled as we are taken through the on-ship court martial procedure of Spock. During which, the limits of reality are tested and pushed as the mysterious aliens (known as the Talosians) take part in distorting the lines of what is and what isn’t an illusion.

The fact that this episode took a much slower pace than any of its predecessors, telling its story through the lens of more of a procedural drama, and focused much more on Captain Pike than the characters we had already come to know, may have turned off some of the show’s more casual viewers of the show. However, in my opinion, this episode represents a controversial theme that was decades ahead of its time. An issue that we are still afraid of and is still uncomfortable to discuss openly today, and not without good measure: the rights of life and death during end-of-life care.

This is by no means a matter to take on lightly, and I won’t pretend that I am in any way an authority on the topic. At the very least I hope to incite open discussion on something growing increasingly relevant in today’s society, especially considering the state of healthcare in the U.S. combined with a culture full of inflated stimulations and addicted to buzzwords and the 24-hour news network.

The plot of The Menagerie, aside from the political side-stories, boils down to the question of what course of care should be taken for the ailing, former-captain Christopher Pike, who has been rendered disfigured and paralyzed due to a delta ray exposure during a maintenance accident.

Wheelchair-bound, and unable to communicate other than using a series of beeps through his chair, Pike is receiving care simply to prolong life as much as possible. His physical state parallels the status quo of end-of-life care in our society today: aiming to elongate life at the expense of costly procedures, trauma and hardship to the family, and, depending on the situation, pain for the individual receiving care.

Throughout the course of the episode, Spock’s plan is unraveled. He sees Pike as a shell of his former shelf; his current physical state acting as a cage for the soul trapped inside. Spock hopes to use the Enterprise to end Pike’s suffering by allowing him to live out the rest of his natural life with the Talosians. It is they who can grant him the illusion of being who he was before the accident, and give him the opportunity to live out his days with the girl he fell in love with on that planet long ago.

Spock’s ideology in pursuing this plot hinges on the concept of end-of-life palliative care. Palliative care is the medical care provided solely to ease pain and the stress and symptoms of serious illnesses – this is most recognized in our society as hospice care.

Today, debates on end-of-life care are far ranging and, many times, hard to decipher. As I mentioned before, our increasing need for stimulation has given greater power and weight to the 24-hour news networks, who revel in twisting and contorting facts in their continued quest for ratings. Since the advent of the Patient Protection and Affordable Care Act of 2010 (aka the ACA & aka ‘Obamacare’), the debate has taken a new position in the spotlight. From the “right-to-die” movement to the Sarah Palin ‘death panel’ fiasco, and now to more current conversations regarding the taxpayer cost of life-elongation treatments, the issue has definitely evolved.

A recent study from the Journal of the American Medical Association has found that, “unwarranted” end-of-life care, which doctors in the study refer to as “futile,” is costing people and hospitals millions at different levels. The study found that, “68% of the patients who received futile treatment died in the hospital, 16% died within six months and the rest remained in chronic poor health.” (Soucre: United Press International article: ‘Study: Futile end-of-life care costs millions, not warranted‘).

I understand that end-of-life care is by no means a black and white issue. On paper, looking towards palliative care becoming the norm seems reasonable and more cost-effective, yet we still can’t speak for every unique case, and we also must remember that we are not talking about numbers, but people. This is what makes me wonder if there is a middle ground – something that will prove to be efficient and humane, while still avoiding futile and unwarranted procedures.

A 2013 bill introduced in Congress, sponsored by U.S. Senators Mark R. Warner (D-VA) and Johnny Isakson (R-GA), would shift the focus away from end-of-life emergency care by creating more incentives and focus on end-of-life counseling and preventative care. This specific bill, the Care Planning Act of 2013, aims to “reimburse medical professionals for the time invested in these end-of-life conversations, develop a public information campaign, and develop quality metrics to measure the effectiveness in delivering the desired medical care.” In other words, the bill will create a medicare and medicaid benefit for patient-centered and personal care counseling, reimburse medical professionals for providing voluntary, structured discussions about the patient’s goals and treatment options, all while providing resources for public and professional education regarding care planning. Aside from this new bill, we’ve seen many efforts to encourage progress in this area, specifically, through the Affordable Care Act and its provisions increasing access to preventative care, expanding medicaid and creating state healthcare exchanges, bolstering insurance coverage for hospice and palliative care, and providing pre-planning educational materials in an attempt to diminish last minute, costly, emergency treatments.

Edit: The bill has since been reintroduced as the Care Planning Act of 2015and – according to the congressional tracking site, govtrack.us – has recently been given a 1% chance of being enacted.

At the end of “The Menagerie,” Captain Pike is given the choice to return to his life of limited existence, or to revisit the Talosians and live out the rest of his life comfortably and on his own terms. Despite knowing the latter choice is simply an illusion, Pike chooses comfort over his current life of despair. This question mirrors countless present day dilemmas in which we must ask ourselves, who is truly benefitting from these aggressive, life-prolonging procedures? In the end, this episode suggests that the answer to that question is not always the individual who is being treated. Spock’s plan for Pike wrapped up nicely by the end of both parts of “The Menagerie,” despite needing two full episodes to convince everyone else he was pursuing the right path. This episode took us through many shades of moral and philosophical grays, and can by no means act as a catch-all answer to questions of this matter in real life. However, one thing I do believe we can take from this is that accepting our own mortality may be one of the hardest challenges life has to offer. Allowing a friend or family member to face that challenge may be painful for the rest of us – nevertheless we must realize that it is their choice to make.